Integrating tactics on opioids

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Science  29 Mar 2019:
Vol. 363, Issue 6434, pp. 1367
DOI: 10.1126/science.aax4353

Many parts of the world are in the middle of an opioid addiction crisis. It is an equal opportunity destroyer, affecting rich and poor, urban and rural people alike. The current epidemic differs from the long-standing heroin addiction problem in its broader demographic and in that it has resulted from inappropriate marketing and overprescription of pain medicines and the intrusion of powerful and lethal synthetic opioids. The magnitude of the crisis is also unprecedented: In the United States alone, more than 2 million people are estimated to have “opioid use disorder,” and 47,000 people died of an opioid overdose in 2017. Traditional strategies for dealing with addiction have had limited success. They have primarily used parallel tactics of “supply control” (limiting availability) and “demand control” (trying to prevent or reduce use), which might be considered as criminal justice and public health approaches. But this side-by-side approach may be counterproductive. Last week, the U.S. National Academies of Sciences, Engineering, and Medicine released a report* on the state of medication-based treatments for opioid addiction. What is clear is that in addition to the need for more research, the nature of the epidemic requires new approaches that integrate public health, regulatory, and criminal justice strategies.

Although additional studies would be useful in refining strategies, there already exists a body of evidence that should be used to improve current tactics. Take the case, for example, of addicted individuals who are accused of or have committed crimes. If these individuals are not treated while they are under criminal justice control, the rates of recidivism to both crime and drug use upon release are extremely high. If, however, they are treated while incarcerated and after release, recidivism rates fall substantially, as do post-release mortality rates. In addition, only 25 to 30% of prison and jail inmates are estimated to receive any drug abuse treatment, whereas over 50% suffer from substance use disorders. Even more dramatic, only 5% of justice-referred individuals receive any of the medications approved by the U.S. Food and Drug Administration (FDA) for their addiction, despite substantial evidence of their effectiveness. The conclusion from that effectiveness research is obvious: It is foolish and borders on being unethical to withhold medical treatment from people with opioid use disorder who are under criminal justice control. There are extensive data that could provide better guidance for refining prevention, prescription, and regulatory policies as well.

The lack of successful strategies to address opioid addiction results in part from other barriers to progress on this epidemic. These include misunderstandings about the nature of addiction and the lack of medications used to treat it, as well as the insidious ideology and stigma that have long surrounded the issue of drug use and addiction. A large body of scientific evidence has established that addiction is a chronic disease of the brain that requires medical intervention. It is not a moral weakness or a failure of will. The stigma surrounding drug use, drug users, and drug treatment have impeded, for example, broader use of the FDA-approved medications because of a mistaken belief that they are merely substituting one addiction for another. In 2016, only 36% of addiction treatment programs in the United States offered any medications at all, and only 6% offered all three approved medications for opioid addiction despite the evidence of their effectiveness.

To make real progress in tackling the opioid epidemic, people on all sides of the issue will have to give up many of their long-held biases and beliefs. Progress will require more researchers working across fields and more informed public health, regulatory, and criminal justice officials, as well as members of the public, agreeing on the actual nature of the opioid crisis and science-based, integrated strategies to deal with it.

  • * A.I.L. chaired the committee of the U.S. National Academies of Sciences, Engineering, and Medicine that released the report “Medications for Opioid Use Disorder Save Lives” (2019).

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